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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 958-961
Bedside diagnosis of lymphorrhea after kidney transplantation surgery: A clinical study


1 Urology Department, Tabriz University of Medical Sciences, Tabriz, Iran
2 Iranian Center of Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Web Publication7-Sep-2015
 

   Abstract 

The aim of our study is to evaluate the role of pyridium (phenazopyridine) in the early bedside differential diagnosis of urine leak and lymphorrhea. Twenty-five kidney recipients (15 males and ten females, aged between 14 and 62 years) with persisting post-operative fluid drainage from the drain for more than two weeks were enrolled in this study. Creatinine and urea of three samples, namely serum, urine and the drain fluid, were measured. A single dose of 300 mg of pyridium (phenazopyridine) was then administered to all patients. One physician and one nurse who were unaware of the aim of the study checked and evaluated the color of the samples of urine and drain fluid of each patient. In seven patients, the level of creatinine in the urine and drain fluid was similar and in them the color of both samples became orange to red, indicating urine leak from the ureteric anstomotic site. The remainder of the 18 patients did not show any changes in the drain fluid color and the level of creatinine was nearly same in the serum and drain fluid. In a kidney transplant recipient, pyridium can be used as an easy, safe and easily available indicator for diagnosing urine leak in the drain fluid.

How to cite this article:
Zomorrodi A, Hajebrahimi S, Zomorrodi S. Bedside diagnosis of lymphorrhea after kidney transplantation surgery: A clinical study. Saudi J Kidney Dis Transpl 2015;26:958-61

How to cite this URL:
Zomorrodi A, Hajebrahimi S, Zomorrodi S. Bedside diagnosis of lymphorrhea after kidney transplantation surgery: A clinical study. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 May 29];26:958-61. Available from: http://www.sjkdt.org/text.asp?2015/26/5/958/164577

   Introduction Top


Kidney transplantation is the preferred treatment for patients with end-stage renal failure. [1] In kidney transplantation, the quality of patient's life is near normal and it has a cost benefit, but the kidney transplant has several surgical, urological and medical complications. Medical complications are induced because of immunosuppressive therapy and include diabetes, hypertension, hyperlipidemia and malignancy.

The urological complications, often due to fault in technique, are urinary leak, ureteric stricture, urinary reflux, urinoma and urinary tract infection. [2] Surgical complications other than urologic are wound infection, hematoma, incisional hernia, lymphorrhea, lymphocele, renal artery stenosis and renal vein thrombosis Lymphorrhea is usually a minor complication after renal transplantation but is the most common cause of fluid collection in the perinephric area. It may develop to lymphocele, which may cause a significant effect on allograft kidney function or can lead to critical complications such as graft loss and rarely even death due to infection. [3]

There are several ways of diagnosing for lymphorrhea, namely ultrasonography, biochemical analysis of the drain fluid, abdomino- pelvic computed tomography or magnetic resonance imaging and scintigraphy of the transplanted kidney. Ultrasonography is an available low-cost diagnostic tool that can be done as a first step. The biochemical values of fluid from lymphorrhea have to be equal with plasma, and it is widely used for the early differentiation of lymphorrhea from urine leak and urinoma. This study is aimed to introduce an easy, safe and low-cost bedside method for the initial differentiation between urine leak and lymphorrhea by using pyridium (phenazopyridine hydrochloride). Phenazopyridine is rapidly excreted by the kidneys, with as much as 65% of an oral dosage being excreted unchanged in urine. Phenazopyridine hydrochloride produces an orange to red color in the urine, and this ability of phenazopyridine helps in the differentiation of urinary leak from lymphorrhea.


   Materials and Methods Top


From March 2001 to November 2013, 25 kidney recipients (15 males and ten females, aged between 14 and 62 years) who had continued drainage of fluid through the inserted drain for more than two weeks during the postoperative period were enrolled in this study in the kidney transplant ward of the Imam Reza Teaching Hospital of Tabriz University of Medical Sciences, Tabriz, Iran. To determine exact nature of the drain fluid, the creatinine and urea values of the drain fluid, serum and urine were measured. All patients were then given a single dose of 300 mg of phenazopyridine and the patient's urine and the drain fluid were collected in separate sterile glass con tainers at the end of the day. One physician and one nurse who were unaware of the aim of the study compared the collected samples of each patient for change in color. Then, the accuracy of the new test was calculated. All patients were given standard care and informed consent was obtained from each of them before enrollment in the study.


   Results Top


In seven patients, the values of creatinine and urea of urine and drain fluid samples were almost the same and the color of urine and drain fluid changed to orange to red color, indicating urinary leak [Table 1]. In the remaining 18 patients, the values of creatinine and urea were same in the drain fluid and serum, but it was quite different from the values from urine samples. In addition, the color of urine after the intake of pyridium got changed but the color of drain fluid was not changed [Table 1]. It means both sensitivity and specificity of colored discharge for diagnosis of urine leak is 100%. [Table 2] shows the amount of urea in the three samples; although the variation of the level of urea almost followed the variation of the level of creatinine, it seems likely that creatinine measurement is more definitive than urea measurement.
Table 1: Level of creatinine in the three types of samples.

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Table 2: Level of urea in the three types of samples.

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   Discussion Top


Kidney transplantation is the first choice for the treatment of patients with end-stage renal failure, and they can have near-normal quality of life by this treatment. [1] Lymphorrhea is one of the common surgical complications of kidney transplant. [3] Lymphorrhea may occur due to leak of lymph from the hilum of allograft kidney or iliac vessel of recipients. [4] The additional risk factors for lymphorrhea and lymphocele formation are use of diuretics, heparin, rejection of the graft and obesity. [5],[6],[7],[8]

The standard diagnosis of lymphorrhea is made by the measurement of urea and creatinine in the urine, serum and drain fluid and comparing the values with each other. In lymphorrhea, the urea and creatinine values will be nearly similar to that of serum whereas, in urinary leak, the amount of creatinine and urea in the drain fluid will be nearly same as that in the urine. As postulated, our study has shown that change of color in the drain fluid after ingestion of pyridium indicates urinary leak. It is an easy, safe and a very low-cost method for the initial differentiation of urine leak from lymphorrhea. The current study showed that the sensitivity and specificity of change of color of the drain fluid after phenazopyridine ingestion for the diagnosis of urine leak in these cases is definitively high (100%). In addition, in those cases with no change of color in the drain fluid, again the accuracy for the diagnosis of lymphorrhea is high.


   Conclusions Top


This study shows that urine with color change after ingestion of phenazopyridine is indicative of urine leak, and clear drainage fluid indicates lymphorrhea. Phenazopyridine administration may be used as an alternative for biochemical evaluation of the drain fluid to differentiate urine leak from lymphorrhea in a kidney transplant patient.

 
   References Top

1.
Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005;25:1335-56.  Back to cited text no. 1
    
2.
Zomorrodi A, Farshi A, Zomorrodi S. The urologic complication in one hundred unrelated live allograft kidney recipients. Open Access Sci Rep 2013;1:1-3  Back to cited text no. 2
    
3.
Lange V, Schardey HM, Meyer G, Illner WD, Petersen P, Land W. Laparoscopic deroofing of post-transplant lymphoceles. Transpl Int 1994;7:140-3.  Back to cited text no. 3
    
4.
Gray DW. Vascular and lymphatic complications after renal transplantation. In: Morris PJ, edr. Kidney Transplantation, Principles and Practice. 5th ed. Philadelphia: WB Saunders;2001. p. 424-6.  Back to cited text no. 4
    
5.
Khauli RB, Stoff JS, Lovewell T, Ghavamian R, Baker S. Post-transplant lymphoceles: a critical look into the risk factors, pathophysiology and management. J Urol 1993;150:22-6.  Back to cited text no. 5
    
6.
Goel M, Flechner SM, Zhou L, et al. The influence of various maintenance immunosuppressive drugs on lymphocele formation and treatment after kidney transplantation. J Urol 2004;171:1788-92.  Back to cited text no. 6
    
7.
Singh D, Lawen J, Alkhudair W. Does pretransplant obesity affect the outcome in kidney transplant recipients? Transplant Proc 2005;37:717-20.  Back to cited text no. 7
    
8.
Lundin C, Bersztel A, Wahlberg J, Wadström J. Low molecular weight heparin prophylaxis increases the incidence of lymphocele after kidney transplantation. Ups J Med Sci 2002;107:9-15.  Back to cited text no. 8
    

Top
Correspondence Address:
A Zomorrodi
Kidney Transplantation Ward, Imam Reza Hospital, Tabriz
Iran
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DOI: 10.4103/1319-2442.164577

PMID: 26354568

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    Tables

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    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusions
    References
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